MRA/HCC CHART REVIEW and DOCUMENTATION GUIDE

An HCC is a category of disease type (e.g., congestive heart failure) with multiple individual ICD-10 diagnoses that map to that HCC category. Each HCC has its own relative Risk Adjustment Factor (RAF) score based on complexity of the disease. HCCs were designed as a risk adjustment system to facilitate reimbursement models based on predicted healthcare service expenditures. Documenting and coding for complete patient diagnosis information across care settings often falls short in the following areas:•Clinicians do not document all relevant conditions for each patient, and thus these conditions are not coded and do not capture the most accurate HCCs.•Clinicians document a patient’s relevant conditions but do not code for the condition, leaving HCC diagnoses in unstructured text in clinical documents.•Patients in an attributed population for a health system do not come in for a visit during the required time period, so there is no opportunity to capture relevant diagnoses for these patients.In the Prospective Model, historical diagnoses are used as a measure of a patient’s health status to predict future expense. There are two components to the health status measurement, which is also known as the Risk Adjustment Factor (RAF), and they are the Demographic Component and the Disease Burden Component. The overall score is relative to the following year’s reimbursement to properly treat and care for the patient. When these chronic conditions are not captured/diagnosed through a face-to-face visit once a calendar year, the reimbursement will fall short for each missed chronic condition acknowledged by the physician/provider.